CurrentmhnPolicy HNCA.CP.MP.496

Gender Affirming Procedures (PDF)

Defines medical necessity criteria for gender-affirming medical and surgical treatment (GAMST) including eligibility, diagnostic criteria for gender dysphoria/incongruence, age-specific requirements, procedure-specific additional criteria (including facial and voice procedures), reconstructive and revision surgery coverage, and coding implications. Applies to Health Net of California members/enrollees, with note that intersex individuals are not subject to these criteria.

Policy Summary

Payermhn

PolicyGender Affirming Procedures (PDF)

Policy CodePolicy HNCA.CP.MP.496

Change TypeIncorporated WPATH SOC-8criteria revisions

Effective DateNov 9, 2011

Next Review Date

Key ActionObtain minimum of one signed written statement recommending GAMST from a competent health care provider able to independently assess and diagnose gender incongruence.

SourceLink

POLICY UPDATE CHANGES

Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8) with modifications reflecting California mandates.

Added gender-affirming facial surgery criteria and list of possible facial procedures.

Revised eligibility and provider qualification language (replaced psychiatrist/psychologist with qualified behavioral health practitioner and set minimum degree requirements).

Clarified revision surgery coverage: medically necessary when addressing complications; revisions for other purposes require reconstructive evaluation.

Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8).

Requirement to live 12 months in desired gender has been removed for adults.

Section III added addressing when revision surgery is medically necessary.

Section V added to address detransitioning.

Hair removal elements removed and replaced with 'Hair removal/electrolysis' phrasing.

Minor rewording to criteria I.A.C.1.B for clarification with no impact to criteria.

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1Required recommendation letters (minimum)

6 moAdult hormone therapy before many procedures

12 moAdolescent hormone therapy before many procedures

>=2Diagnostic indicators required

WPATH SOC-8Guideline Source

Coverage Summary

Defines medical necessity criteria for gender-affirming medical and surgical treatment (GAMST) for Health Net of California members/enrollees, including diagnostic requirements for gender dysphoria/gender incongruence, age-specific eligibility, and procedure-specific additional criteria (facial and voice procedures, reconstructive and revision surgery). Notes that intersex individuals are not subject to these criteria. The policy incorporates and adapts WPATH Standards of Care Version 8 (SOC-8) and California regulatory guidance (including APL 20-018 and state Health & Safety Code references) to reflect state mandates and operationalize SOC-8 requirements for Health Net of California.

Adult hormone therapy duration (>=18 years)>= 6 months prior to many procedures unless hormone therapy is not desired or is medically contraindicated

Minor hormone therapy duration (<18 years)>= 12 months prior to many procedures (including facial procedures) unless hormone therapy is not desired or is medically contraindicated

Voice deepening trial>= 2 years of consistent masculinization hormone therapy (voice deepening surgery considered if voice fails to deepen)

Diagnostic symptom threshold>= 2 indicators of marked and sustained incongruence from listed criteria (per A.1)

Tanner stage requirement for minors>= Tanner stage 2 required for GAMST assessment for members <18 years

One recommendation letterMinimum of one written signed statement recommending GAMST required for genital surgery eligibility

Medical Necessity Criteria (Eligibility and Procedure-specific)

I. Medical Necessity General Policy

I. Medical Necessity General Policy: Gender-affirming surgeries are considered medically necessary when both A (Diagnosis) and B (Eligibility) are met. Intersex individuals are not subject to the criteria in this policy.

Policy-level operational references: See sections A (Gender Dysphoria or Gender Incongruence Criteria) and B (Eligibility criteria) for required diagnostic and eligibility determinations prior to approval of gender-affirming procedures.

A. Gender Dysphoria or Gender Incongruence Criteria

A. Gender Dysphoria or Gender Incongruence Criteria: Marked and sustained incongruence indicated by at least two of the following.

n_of:2; a) Marked incongruence between experienced/expressed gender and primary and/or secondary sex characteristics; b) Strong desire to be rid of one's primary and/or secondary sex characteristics because of marked incongruence; c) Strong desire for the primary and/or secondary sex characteristics of the other gender; d) Strong desire to be of the other gender (or some alternative gender different from one's assigned gender); e) Strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender); f) Strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender); g) Condition associated with impairment in social, occupational, or other important areas of functioning.

Policy-level Updates & Operational References

Key material updates from adopting WPATH SOC-8: a single referral letter is now required for genital surgery; adults (≥18) generally require a minimum of 6 months of hormone therapy before many procedures while minors have a minimum of 12 months; the prior 12‑month living in desired gender requirement for adults was removed; new numbered sections were added (notably Sections III for revision surgery and V for detransitioning); gender-affirming facial procedures and voice modification criteria were reorganized (facial/voice surgery moved into Section II and II.a respectively); hair removal language was simplified to “Hair removal/electrolysis”; and provider qualification and documentation expectations were expanded.

Operational references in the policy explicitly point to: a one-letter requirement for genital surgery (I.A / genital surgery criteria); hormone therapy duration requirements for adults (≥18) and minors (<18) (I.C.2; 5.a.iii; 5.b; C.1); hair removal/electrolysis as a procedure-level requirement (II.B.4); and voice modification surgery criteria (II.B.13).

Provider Actions — Documentation, Prior Authorization, and Qualifications

Documentation Required

One written recommendation for GAMST

Minimum of one written statement with signature recommending gender-affirming medical and surgical treatment (GAMST) is required from a health care provider competent to independently assess and diagnose gender incongruence.

Documentation Required

Assessment documentation

Assessment must identify any mental or physical health conditions that could negatively impact GAMST outcomes and document risks/benefits discussion. The assessment must note the member's capacity to understand reproductive effects of GAMST and document discussion of reproductive options prior to initiation of GAMST.

Documentation Required

Provider qualifications — minimum degree & licensure

Assessing providers must be qualified and licensed by their statutory body. For adults and adolescents the assessor should have experience in or be qualified to assess gender dysphoria/incongruence (examples: mental health professional, general medical practitioner, nurse, or other qualified provider) and hold at minimum a master’s degree in a clinical field related to transgender health or equivalent further clinical training and statutory regulation.

Coding (Informational CPT list)

CPT codes that may be considered part of gender-affirming surgery (informational list)CPT

11950	Subcutaneous injection of filling material (eg, collagen)
11951
11952
11953
11954
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion
11970	Replacement of tissue expander with permanent implant
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less

1–10 of 142

1/15

Coding lists in this policy are provided for informational purposes only and do not by themselves determine coverage. Coverage determinations depend on meeting the policy's clinical criteria and applicable benefit terms. Providers should verify billing modifiers, payer-specific prior authorization requirements, and use current coding guidance before submitting claims.

Background, Evidence & Definitions

Background: This policy aligns Health Net of California criteria with the World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 (SOC-8), adapted where necessary to reflect California mandates (including APL 20-018 and applicable state law). The policy emphasizes individualized assessment and that not all members will require the same interventions, while setting defined diagnostic, age-based, and procedure-specific requirements consistent with SOC-8 and state regulatory guidance.

Source	Reference
Source guideline
WPATH Standards of Care version 8 (SOC-8) referenced and incorporated
Regulatory reference
California Health & Safety Code 1367.63; APL 20-018

Term	Definition
GAMST
Gender-affirming medical and surgical treatment
Intersex individuals
Individuals with disorder of sexual development; noted as not subject to same criteria in this policy

Medicare Determinations

Name	Number	Effective Date	Type
Gender Reassignment Services for Gender Dysphoria (Local Coverage Article referenced)
A53793 (Local Coverage Article referenced)
2015-10-01 (LCA published; revised 2021-01-01)
NCD

Revision History

06/25revisedLatest

Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8) with modifications reflecting California mandates and policy-level updates; removed 12-month living requirement and clarified hormone therapy durations; added sections for revision surgery and detransitioning; facial surgeries moved to Section II.

02/23revised

Corporate policy adoption of WPATH SOC-8: one letter required for genital surgery; adults >=18 require minimum 6 months of hormone therapy prior to many procedures; minors have 12-month hormone therapy requirement for many procedures; removed requirement to live 12 months in desired gender.

Policy Summary

Payermhn

PolicyGender Affirming Procedures (PDF)

Policy CodePolicy HNCA.CP.MP.496

Change TypeIncorporated WPATH SOC-8criteria revisions

Effective DateNov 9, 2011

Next Review Date

Key ActionObtain minimum of one signed written statement recommending GAMST from a competent health care provider able to independently assess and diagnose gender incongruence.

SourceLink

On This Page

B. Eligibility criteria (all of the following)

B. Eligibility criteria — all of the following must be met.

ALL of the following

Capacity to make a fully informed decision (including awareness of potential effects of treatment on fertility) and to consent for treatment.
If significant medical or mental health concerns are present, they are reasonably well controlled.
Other possible causes of apparent gender dysphoria, gender incongruence, or gender diversity have been identified and excluded.
Minimum of one written statement with signature recommending gender-affirming medical and surgical treatment (GAMST) from a health care provider competent to independently assess and diagnose gender incongruence.
Age-based pathway
- For members ≥ 18 years
  - Assessment for GAMST from a provider who: (a) has experience in or is qualified to assess clinical aspects of gender dysphoria/incongruence/diversity (e.g., mental health professional, general medical practitioner, nurse, or other qualified health care provider); and (b) is licensed by their statutory body and holds, at minimum, a master's degree in a clinical field related to transgender health or equivalent further clinical training and is statutorily regulated.
  - The documented assessment for GAMST must: (a) identify any mental or physical health conditions that could negatively impact the outcome of GAMST, with risks and benefits discussed; and (b) note the member's capacity to understand the effect of GAMST on reproduction and include a discussion of reproductive options prior to initiation of GAMST.
  - Member remains stable on their gender-affirming hormonal treatment regimen which may include at least six months of hormone treatment or longer if required to achieve the desired surgical result, unless hormone therapy is not desired or is medically contraindicated.
- For members < 18 years
  - Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
  - Has reached Tanner stage 2.
  - Has been informed of the reproductive effects of GAMST, including potential loss of fertility and available options to preserve fertility; discussion documented in context of adolescent's pubertal development.
  - Has completed a minimum of 12 months of gender-affirming hormone therapy or longer if required to achieve the desired surgical result for gender-affirming procedures (including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery), unless hormone therapy is not desired or is medically contraindicated.
  - Assessment for GAMST from a provider who: (a) has experience in or is qualified to assess clinical aspects of gender dysphoria/incongruence/diversity; and (b) is licensed by their statutory body and holds, at minimum, a master's degree in a clinical field related to transgender health or equivalent further clinical training and is statutorily regulated.

C. Procedure-specific medically necessary surgeries when above criteria met

C. Procedure-specific medically necessary surgeries when above criteria met. Requirements differ by age group and by procedure.

ANY of the following

For members < 18 years
- Requested procedure is one of: penectomy; urethroplasty; mammoplasty; mastectomy (member assessed for breast cancer risk factors); clitoroplasty; vulvoplasty; labiaplasty; vaginectomy; vulvectomy; scrotoplasty; testicular prosthesis.
- Twelve months of hormone therapy has been administered (unless hormone therapy is not desired or is medically contraindicated) and requested procedure is one of: breast augmentation (member assessed for breast cancer risk factors); phalloplasty; metoidioplasty; vaginoplasty; gonadectomy (hysterectomy, orchiectomy).
For members ≥ 18 years
- Requested procedure is one of: penectomy; urethroplasty; mammoplasty; mastectomy (member assessed for breast cancer risk factors); clitoroplasty; vulvoplasty; labiaplasty; vaginectomy; vulvectomy; scrotoplasty; testicular prosthesis; breast augmentation (member assessed for breast cancer risk factors); phalloplasty; metoidioplasty; vaginoplasty; gonadectomy (hysterectomy, salpingo-oophorectomy, orchiectomy).
- At least six months of hormone therapy may be considered prior to procedure, as appropriate for the member's goals (unless hormone therapy is not desired or is medically contraindicated).

Operational note: For all procedures requiring assessment of breast cancer risk factors, documentation of the assessment must be included in the clinical record.

II. Gender-affirming facial procedures

II. Gender-affirming facial procedures: Considered medically necessary on a case-by-case basis when criteria I.A. and I.B. are met and the requested procedure intends to correct facial appearance that demonstrates significant variation from standard appearance for the experienced gender.

For members < 18 years, 12 months of hormone therapy is required prior to facial surgery as part of gender-affirming treatment unless hormone therapy is not desired or medically contraindicated.

Possible procedures (include but are not limited to): blepharoplasty; face lift/mid-face lift/brow lift; facial implants and bone reconstruction; hair removal/electrolysis; drugs for hair loss or growth; hair transplantation or hairline advancement; prosthetic or filler substances to alter contour; rhinoplasty; thyroid chondroplasty; removal of redundant skin; upper lip shortening and lip augmentation; chondrolaryngoplasty; voice modification surgery, therapy, or lessons.

II.a Voice modification surgery specifics

II.a Voice modification surgery specifics: Distinctions and documentation/trial requirements for voice deepening versus voice feminization procedures.

ANY of the following

Voice deepening surgery (e.g., thyroplasty)
- Considered medically necessary if the voice fails to deepen after 2 years of consistent masculinization hormone therapy.
Voice feminization surgery (e.g., cricothyroid approximation or CTA)
- Considered medically necessary when all of the following are met: documentation of diagnosis of transgenderism (per WPATH) by qualified professionals; documentation that voice therapy has been provided and proven ineffective as attested by a qualified voice therapist (trans-sensitive speech-language therapist using standard voice and communication protocols); documentation of completed pre-operative assessments by both a laryngologist and a speech-language therapist who agreed to the clinical benefits in achieving transitional goals; documentation that a qualified voice and communication specialist (licensed and/or credentialed by the board responsible for speech therapists/speech-language pathologists) will follow the patient postoperatively to maximize surgical outcome.

Operational note: Pre- and post-operative documentation by qualified voice specialists must be included in the medical record.

III. Revision procedures

III. Revision procedures: Medically necessary when required to address complications of a prior gender-affirming procedure.

Revision procedures are considered medically necessary when addressing complications such as wound dehiscence, fistula, chronic pain directly related to the prior surgery, or other complications that impair function or healing.

Examples of revision-related indications: correction of fistula, repair of wound dehiscence, management of chronic surgical-site pain attributable to prior gender-affirming surgery.

IV. Medically necessary reconstructive surgery

IV. Medically necessary reconstructive surgery: Procedures used specifically to improve appearance for individuals undergoing gender reassignment or actively participating in a documented gender reassignment treatment plan must be evaluated for medical necessity to create a normal appearance for the gender with which the member identifies.

Possible reconstructive procedures include: abdominoplasty; liposuction; skin resurfacing; mastopexy; revision procedures for purposes other than correction of complications.

Operational note: Prior to a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.

V. Detransition procedures

V. Detransition procedures: Considered for medical necessity on a case-by-case basis.

Detransition procedures by gender-related hormone intervention, surgical intervention, or both will be evaluated on a case-by-case basis.

Documentation Required

Document hormone therapy duration or contraindication

Document duration of gender-affirming hormone therapy when required by procedure-specific criteria (e.g., ≥6 months for many adult procedures; ≥12 months for certain procedures in adolescents), or clearly document that hormone therapy is not desired or is medically contraindicated.

≥6 months hormone therapy for many adult procedures, unless not desired or contraindicated
≥12 months hormone therapy required for many procedures in members <18 years unless not desired or contraindicated
If hormone therapy is contraindicated or not desired, document reason

Documentation Required

Letter from qualified provider required for genital surgery

For genital surgery, a letter from a qualified provider documenting eligibility and addressing required criteria (diagnosis, capacity, stability, assessments, hormone therapy status or contraindication, and discussion of reproductive effects) is required prior to approval.

Letter must be signed and from a provider competent to assess gender incongruence
Letter should reference assessment findings, hormone therapy status, and reproductive counseling

Prior Authorization

Prior clinical review may be required for reconstructive determinations

Prior clinical review may be required to determine whether procedures meet reconstructive (medically necessary) criteria versus cosmetic. Clinical review may include consultation with a licensed mental health professional and the treating surgeon and should evaluate whether the requested procedure is necessary to create a normal appearance for the gender with which the member identifies.

Examples of procedures that may need review: abdominoplasty, liposuction, skin resurfacing, mastopexy, revision procedures for non-complication reasons

Documentation Required

Voice surgery prerequisites (therapy, assessments, follow-up plan)

Voice feminization surgery requires documentation of: a diagnosis of transgenderism by qualified professionals per WPATH definitions; prior voice therapy that was attempted and documented ineffective (attestation from a trans‑sensitive speech‑language therapist); completed preoperative assessments by both a laryngologist and speech‑language therapist agreeing clinical benefit; and a postoperative follow‑up plan with a qualified voice and communication specialist.

Diagnosis documented per WPATH
Documentation of prior voice therapy and its ineffectiveness with attestation from qualified therapist
Preoperative assessments by laryngologist and speech‑language therapist
Postoperative follow‑up plan with licensed/credentialed voice and communication specialist

Documentation Required

Hair removal / electrolysis documentation when required

When hair removal (including electrolysis) is required by the planned surgical procedure (for example, prior to vaginoplasty or certain facial procedures), document the hair removal treatment plan and completion status, or rationale if not done.

Document number and dates of hair removal/electrolysis sessions when required
If hair removal cannot be completed, document clinical rationale and alternative management

Added gender-affirming facial surgery criteria and enumerated possible facial procedures; simplified hair removal phrasing to 'Hair removal/electrolysis'; voice modification criteria relocated to facial procedures section with no substantive change.

05/21revised

Revised eligibility and provider qualification language: replaced psychiatrist/psychologist with qualified behavioral health practitioner and set minimum degree requirements; allowed second referral letter from a qualified mental health provider and specified adolescent provider characteristics.

04/21revised

Revised criteria to allow second referral letter from a qualified mental health provider and removed requirement for 12 months living in associated gender for chest surgery; replaced 'electrolysis' with broader 'hair removal' terminology.

11/20added

Added reference to California APL 20-018 Ensuring Access to Transgender Services and noted policy adaptations to reflect state mandates.

06/25clarified

Minor rewording to criteria I.A.C.1.B for clarification with no impact to criteria (administrative wording change).